The nurse cares for a client who is experiencing exophthalmos as a complication of Graves' disease. Which nursing action(s) should be included in the client's plan of care? Select all that apply.

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11ecbb05_c971_c6cb_b433_357ec7ee5ffb_MD0009_00 Exophthalmos is a complication of hyperthyroidism (hypermetabolic state due to thyroid hormone overproduction) from Graves' disease. It is defined as a protrusion of the eyeballs caused by increased orbital tissue (connective, adipose, muscular) expansion and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection. Nursing care for a client with exophthalmos includes: Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area Using artificial tears or other similar products to moisten the eyes to prevent corneal drying (causes abrasions/ulcers) Taping the client's eyelids shut during sleep if they do not close on their own Teaching the client the following: Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate condition.If recommended, anti-thyroid drugs should be taken to prevent further exacerbation of exophthalmos.Smoking cessation is necessary as smoking increases the risk of Graves' disease and associated eye problems.Restrict salt intake to decrease periorbital edema.Use dark glasses to decrease glare and prevent external irritants and infection.Perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility. Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate condition. If recommended, anti-thyroid drugs should be taken to prevent further exacerbation of exophthalmos. Smoking cessation is necessary as smoking increases the risk of Graves' disease and associated eye problems. Restrict salt intake to decrease periorbital edema. Use dark glasses to decrease glare and prevent external irritants and infection. Perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility. Educational objective: Exophthalmos is a complication of hyperthyroidism from Graves' disease leading to increased orbital tissue (connective, adipose, muscular) expansion that can be irreversible. Nursing care to keep eyes moist and protected is needed to prevent corneal ulcers and infection.

The Nurse Cares for a Client Who Is Experiencing Exophthalmos